Uterine cervix cancer

What three structures form the vestibule (triangular space located ant to vaginal opening and contains female urethra)

Labia majora and labia minora, clitoris

Three layers of vaginal wall

Mucosa, muscularis, adventitia

Three main parts of uterus

Cervix, body, fundus

Three layers of uterine walls

inner endometrium, middle myometrium, outer perimetrium

Function of fallopian tubes

Transfer ova from ovaries to uterus

Cervix

Lowest part of the uterus where it connects with superior portion of vagina

Two parts of cervix

Endocervix- inner opening of cervix to uterus

• glandular cells

Exocervix- outer part of cervix visible during speculum exam

• squamous cells

Pre-cancer of the cervix

Abnormal cells:

• Cervical intraepithelial neoplasia (CIN)

• Squamous intraepithelial lesion (SIL)

• Dysplasia

Treating cervical pre-cancers can prevent almost all cervical cancers

True

Cervical pre-cancer is diagnosed more often than invasive cervical cancer

True

Treatment for pre-cancer

Surgery

• Cryosurgery

• Laser surgery

• Conization

• Ablation

Cervical cancer incidence rates have declined because of ________

Screening uptake and HPV vaccination

Death rate is highest in which races?

Black and Native American

What risk factor is prevalent in >90% of cases?

HPV

Highest risk HPV subtypes

16 and 18

Most HPV infections ________

Clear within 2 years without progressing into cancer

HPV needs _____ to progress into cervical cancer

10-20 years

HPV vaccine

Recommended for use in girls 9 to 11 years of age, but may be given up to age 26

Cannot protect against established infections

Does not protect against all subtypes of HPV

PAP test

Speculum is inserted in the vagina. Samples are taken from exocervix and endocervix and evaluated in a lab

PAP results

• Negative

• Epithelial cell abnormalities

• Other malignant neoplasms

Epithelial cell abnormalities from PAP test

Cells lining the cervix or vagina show changes that might be cancer or a pre-cancer

• squamous cells

• glandular cells

Cervical cancer is ________ in early stages

Asymptomatic

Most common clinical presentation

Abnormal vaginal bleeding

What age group is PAP test recommended?

25-65

PAP test is recommended to be performed every ___ years with ________

Every 5 yrs with clinician-collected cervical specimen

Women who have had a hysterectomy still need to participate in PAP screening

False

___ of women diagnosed with cervical cancer in the US were never screened

Half

___ of women diagnosed with cervical cancer in the US were not screened in the past 5 years

10%

Chest x-ray

Used to detect mets

MRI and CT

Can detect lymph node involvement and evaluate parametrial and vaginal extension; excludes those with a pacemaker or metal prosthetic in the area

PET/CT

Most widely used exam for staging, excellent in detecting lymph involvement and detection of distant mets in lung, liver, and bone

Colposcopy

Microscopic procedure to examine cervix for visible abnormalities (performed on women with abnormal pap smear results and/or at high risk for cervical cancer)

Punch biopsy

Removes small piece of tissue with forceps

Endocervical curettage

Removes tissue from the endocervical canal

Cone biopsy/ conization

A cone shaped piece of tissue is removed from cervix (exocervix or endocervix) and examined by a pathologist

Conization is performed when ________

No tumor is visible on the cervix, but the clinician suspects an endocervical tumor

Two types of cone biopsies

LEEP and cold knife biopsy

LEEP (loop electro-surgery procedure)

A thin wire loop is heated with electric current

When are cystoscopy and proctoscopy used?

Only if imaging exam or patient symptoms reveal possible bladder or rectal invasion

Most common pathology type (80-90%)

SCC (originate in squamous cells of exocervix)

Less common pathology types

Adenocarcinoma, clear cell carcinoma

• Arise inside of the endocervical mucus producing gland cells

Which pathology type has worse prognosis, and why?

Adenocarcinoma, clear cell carcinoma due to bulkiness, high metastatic rate

Direct spread

To bladder and rectum

Metastatic spread

To lungs, bone, liver

Spread typically begins at ________

Endocervical canal or at external os

Lymphatic spread

Orderly (but not always)

Involving obturator, internal iliac, and external iliac

Distant spread to paraaortic, mediastinal, and supraclavicular nodes

Most common staging system for Gyn cancers is ________

FIGO

FIGO Stage I

Cervical carcinoma confined to the uterus (disregard extension to the corpus)

FIGO Stage II

Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina

FIGO Stage III

Tumor extends to pelvic wall or involves lower third of vagina or causes hydronephrosis or nonfunctional kidney

FIGO Stage IV

Tumor invades mucosa of bladder or rectum or extends beyond true pelvis (bullous edema is not sufficient to classify a tumor as T4)

Treatment choices are based on…

Extension of primary disease

Sites of possible regional involvement

Performance status of patient

Preservation of childbearing function

Radiation therapy may be used to treat which stages?

All stages

When may surgery be used to treat?

Medically operable conditions in early stages for whom cure rates are similar and morbidity may be less

Patients with stages Ib2 or greater are usually treated with ________

Radiation alone or in combination with chemotherapy

Localized cancer is typically treated with ________

Surgery, radiation, or a combination of the two

Total abdominal hysterectomy with or without small amount of vaginal tissue called the vaginal cuff is used to treat which stages?

Stage 0 and stage 1A

Simple hysterectomy

Remove entire uterus and cervix

Radical trachelectomy

Cervix is removed, uterus remains

• Patient maintains fertility

Radical hysterectomy

Removal of uterus, ligaments, and 1-2 inches of deep vagina around the cervix

• Paraaortic lymph node dissection

Chemotherapy is typically used as a ________ treatment

Adjuvant

Advanced disease can be treated with

• EBRT and chemo

• EBRT and brachy

Combined modalities should be considered if there is ________

High risk of recurrence or

Neither treatment alone would control the disease